Factor structure and validity of the Medication Adherence Questionnaire (MAQ) with cigarette smokers trying to quit

An effectiveness-implementation hybrid trial of phone-based tobacco cessation interventions in the Lebanese primary healthcare system: protocol for project PHOENICS

BACKGROUND

Tobacco use remains the leading cause of preventable disease, disability, and death in the world. Lebanon has an exceptionally high tobacco use burden. The World Health Organization endorses smoking cessation advice integrated into primary care settings as well as easily accessible and free phone-based counseling and low-cost pharmacotherapy as standard of practice for population-level tobacco dependence treatment. Although these interventions can increase access to tobacco treatment and are highly cost-effective compared with other interventions, their evidence base comes primarily from high-income countries, and they have rarely been evaluated in low- and middle-income countries. Recommended interventions are not integrated as a routine part of primary care in Lebanon, as in other low-resource settings. Addressing this evidence-to-practice gap requires research on multi-level interventions and contextual factors for implementing integrated, scalable, and sustainable cessation treatment within low-resource settings.

METHODS

The objective of this study is to evaluate the comparative effectiveness of promising multi-component interventions for implementing evidence-based tobacco treatment in primary healthcare centers within the Lebanese National Primary Healthcare Network. We will adapt and tailor an existing in-person smoking cessation program to deliver phone-based counseling to smokers in Lebanon. We will then conduct a three-arm group-randomized trial of 1500 patients across 24 clinics comparing (1) ask about tobacco use; advise to quit; assist with brief counseling (AAA) as standard care; (2) ask; advise; connect to phone-based counseling (AAC); and (3) AAC + nicotine replacement therapy (NRT). We will also evaluate the implementation process to measure factors that influence implementation. Our central hypothesis is that connecting patients to phone-based counseling with NRT is the most effective alternative. This study will be guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, supported by Proctor's framework for implementation outcomes.

DISCUSSION

The project addresses the evidence-to-practice gap in the provision of tobacco dependence treatment within low-resource settings by developing and testing contextually tailored multi-level interventions while optimizing implementation success and sustainability. This research is significant for its potential to guide the large-scale adoption of cost-effective strategies for implementing tobacco dependence treatment in low-resource settings, thereby reducing tobacco-related morbidity and mortality.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05628389, Registered 16 November 2022.

Medication Adherence in Tobacco Cessation Clinical Trials

Adherence is a critical mediator of treatment outcome across health conditions and low rates of adherence undermine success in smoking cessation treatment. This narrative review provides an overview of different techniques that can be used to measure adherence to smoking cessation treatments and outlines strategies to address treatment adherence. Techniques to measure adherence include conducting pill counts, collecting self-reports of adherence, directly observed therapy, biochemical verification methods, and electronic data collection via medication events monitoring systems. Techniques examined for increasing tobacco cessation treatment adherence include counseling, automated adherence calls, feedback from electronic monitors, contingency management and directly observed therapy. Adherence monitoring and optimization should be a standard component of smoking cessation treatment research.

The Associations among Gender, Age, eHealth Literacy, Beliefs about Medicines and Medication Adherence among Elementary and Secondary School Teachers

Background: A lack of health literacy may negatively impact patient adherence behavior in health care delivery, leading to a major threat to individual health and wellbeing and an increasing financial burden on national healthcare systems. Therefore, how to cultivate citizens’ health literacy, especially electronic health (eHealth) literacy that is closely related to the Internet, may be seen as a way to reduce the financial burden of the national healthcare systems, which is the responsibility of every citizen. However, previous studies on medication adherence have mostly been conducted with chronic disease patient samples rather than normal samples. Teachers are not only the main body of school health efforts, but also role models for students’ healthy behavior. Therefore, understanding differences in eHealth literacy beliefs among schoolteachers would be helpful for improving the existing health promoting programs and merit specific research. Aims: The present study identified the relationships among gender, age, electronic health (eHealth) literacy, beliefs about medicines, and medication adherence among elementary and secondary school teachers. Methods: A total of 485 teachers aged 22−51 years completed a pen-and-paper questionnaire. The instruments included an eHealth literacy scale, a belief about medicines scale and a medication adherence scale. Results: The results showed a significant difference between genders in necessity beliefs about medication (t = 2.00, p < 0.05), and a significant difference between ages in functional eHealth literacy (F = 3.18, p < 0.05) and in necessity beliefs about medication (Welch = 7.63, p < 0.01). Moreover, age (β = 0.09), functional eHealth literacy (β = 0.12), and necessity beliefs about medication (β = 0.11) positively predicted medication adherence, while concerns about medication (β = −0.23) negatively predicted medication adherence. Conclusions: The results showed that male teachers had stronger concerns about medication than female teachers. Teachers aged 42−51 years had lower functional eHealth literacy and stronger necessity beliefs about medication than teachers aged 22−31 years. In addition, teachers who were older, had higher functional eHealth literacy, had stronger necessity beliefs about medication, and had fewer concerns about medication tended to take their medications as prescribed. These findings revealed that helping teachers develop high eHealth literacy and positive beliefs about medicines is an effective strategy for improving medication adherence.

Optimizing tobacco treatment delivery for people with HIV: trial protocol for a randomized controlled trial

BACKGROUND

With advances in antiretroviral therapy, people with HIV (PWH) are living longer and are less likely to die from AIDS-related complications. Yet, prior research has shown that smoking is often not addressed in the context of HIV care, and few individuals are offered cessation treatment. Optimizing tobacco treatment delivery for PWH may increase engagement with evidence-based treatments and successful quit attempts.

METHODS

The current study is a type 1 hybrid effectiveness-implementation trial to evaluate the impact of a proactive, opt-out tobacco treatment intervention on cessation outcomes and advance understanding of key barriers and facilitators of implementation processes. A total of 230 PWH who smoke will be recruited from an infectious diseases clinic at an academic medical center and will be randomized to receive (1) treatment as usual (TAU) or (2) Proactive Outreach with Medication Opt-out for Tobacco Treatment Engagement (PrOMOTE). Primary outcomes include: biochemically verified 7-day point prevalence abstinence (PPA) rates, continuous abstinence (Weeks 9-12), and the number of 24-hour quit attempts at the end of study treatment (Week 12). Secondary outcomes include: participant reach (proportion reached out of contact attempts), implementation fidelity (including number of prescriptions written), participant adherence to prescribed pharmacotherapy, acceptability (participant and provider satisfaction with intervention delivery and content), and perceived barriers.

DISCUSSION

This study will examine a novel approach to optimizing tobacco treatment delivery for PWH. Integrating effectiveness and implementation results will help define best practices for engaging PWH with evidence-based tobacco treatment interventions. The intervention is low-cost, has the potential to be highly scalable, and could be translatable to other ambulatory HIV clinic settings.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05019495 (August 24, 2021).

Preoperative contingency management intervention for smoking abstinence in cancer patients: trial protocol for a multisite randomised controlled trial

INTRODUCTION

Continued smoking following a cancer diagnosis has substantial health risks including increased overall and cancer-specific mortality, risk of secondary malignancies, cancer treatment toxicity and risk of surgical complications. These risks can be mitigated by quitting smoking. The preoperative period represents a prime opportunity in which to administer robust smoking cessation treatment to both improve health and support and improve surgical outcomes. We will conduct a randomised clinical trial to evaluate the effectiveness of financial incentives delivered contingent on biochemically verified smoking abstinence (contingency management (CM)) in patients with cancer undergoing surgery.

METHODS AND ANALYSIS

The study will take place across two study sites, and participants (N=282) who smoke, are diagnosed with or suspected to have any type of operable cancer and have a surgical procedure scheduled in the next 10 days to 5 weeks will be randomised to receive standard care plus Monitoring Only or CM prior to surgery. All patients will receive breath carbon monoxide (CO) tests three times per week, nicotine replacement therapy and counselling. The CM group will also earn payments for self-reported smoking abstinence confirmed by CO breath test ≤4 ppm on an escalating schedule of reinforcement (with a reset if they smoked). Point prevalence abstinence (PPA) outcomes (self-report of 7-day abstinence confirmed by CO≤4 ppm and/or anabasine ≤2 ng/mL) will be assessed on the day of surgery and 6 months after surgery. The effect of CM on 7-day PPA at the time of surgery and 6-month follow-up will be modelled using generalised linear mixed effects models.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the Medical University of South Carolina Institutional Review Board. We will disseminate our scientific results through traditional research-oriented outlets such as presentations at scientific meetings and publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04605458.

Selected psychological factors and medication adherence in patients with rheumatoid arthritis

Objectives

The aim of the study was to determine the relationship between medication adherence (MA) and selected psychological factors in a group of patients with rheumatoid arthritis (RA).

Material and methods

The cross-sectional study was conducted in four rheumatology outpatient clinics in Silesia, Poland. The tests used were the Medication Adherence Questionnaire (MAQ), the Multidimensional Health Locus of Control Scale (MHLC), the Coping Inventory for Stressful Situations (CISS), and the Mindful Attention Awareness Scale (MAAS). The analysis involved 106 adult patients diagnosed with RA at least 6 months before, who were prescribed medication, with disease at any stage and with stable comorbidities. Software was used to perform analyses of frequency, basic descriptive statistics, including the Kolmogorov-Smirnov test, Student’s t-test for independent samples, intergroup univariate variance, Pearson’s r correlation coefficient, Spearman’s rank correlation ρ coefficient, Fisher’s exact test and stepwise linear regression.

Results

Powerful Others Health Locus of Control (PHLC), Internal Health Locus of Control (IHLC) and age of the subjects, F(3, 102) = 8.05; p < 0.001 explained 16.8% of the variation in the adherence level for the entire group. In the group of women PHLC and IHLC, F(2, 80) = 10.04; p < 0.001 were included in the model, which explained 18.1% of variation in MA. PHLC was the most significant factor in the group of women (β = 0.55; p < 0.001) and in the entire group (β = 0.48; p < 0.001). In the group of men, Social Diversion Style (SDS), F(1, 21) = 5.81; p = 0.02 was included in the model, which explained 17.9% of the variation in the MA level.

Conclusions

The study identified some psychological predictors of adherence, which explained 16.8% of the variability. Factors increasing the likelihood of medication adherence in patients with rheumatoid arthritis include a strong belief in the power of others, low level of internal health locus of control, and advanced age.

Selected psychological predictors of medication adherence in the older adults with chronic diseases

Aim

The main goal of the study was to assess the significance of selected psychological factors related to the adherence to medication recommendations among the older adults with chronic diseases.

Design

It was designed as a cross-sectional study, aimed at assessing the importance of selected psychological factors in complying with medication recommendations among older adults.

Methods

The study involved 345 older adults with chronic diseases, assessed the importance of selected psychological factors, such as: health locus of control, stress coping and mindfulness in adhering to medication recommendations older persons. To answer the research questions, we performed frequency analyses, basic descriptive statistics analyses together with the Kolmogorov-Smirnov test, Student's t tests for independent samples, monofactorial analysis of variance in the intergroup diagram, analysis correlation with the Pearson correlation coefficient, Spearman's rank correlation ρ analysis and stepwise linear regression analysis.

Results

The study identified psychological predictors of medication adherence, which explained 12% of the variability. An emotion-oriented coping proved to be the most important factor. Additionally, powerful other health locus of control and mindful attention were shown to have a positive effect.

Illness Perceptions, Self-efficacy, and Self-reported Medication Adherence in Persons Aged 50 and Older With Type 2 Diabetes

BACKGROUND

Illness perceptions, patients' beliefs about their health condition, may affect medication adherence as well as self-efficacy for managing the condition in type 2 diabetes (T2DM).

OBJECTIVES

The aims of this study were to investigate the associations between illness perceptions, self-efficacy, and self-reported medication adherence among persons (≥50 years of age) with T2DM and explore whether the number of comorbid conditions moderates these associations.

METHODS

This secondary analysis of cross-sectional data used baseline data from persons with T2DM. Self-administered questionnaires, including the Brief Illness Perception Questionnaire, Self-efficacy for Managing Chronic Disease, and the 4-item Morisky-Green-Levine Medication Adherence Scale, were used. We performed hierarchical multiple linear regression analyses.

RESULTS

Participants (N = 146) were 57.5% female, 67.1% white, and on average 64 years old. Six dimensions of illness perceptions (ie, consequences, personal control, treatment control, identity, concerns, and emotional representations) were associated with self-efficacy for managing T2DM. Five dimensions (ie, timeline, personal control, treatment control, coherence, and emotional representations) were significant predictors of self-reported medication adherence. Whereas the number of comorbid conditions was significantly associated with self-efficacy for managing T2DM in all models (P values < .001), the number of comorbid conditions was not associated with self-reported medication adherence.

CONCLUSIONS

This study suggests that illness perceptions and comorbid conditions may play a critical role in either self-efficacy or self-reported medication adherence in persons (≥50 years of age) with T2DM. Future research should incorporate an individual's illness perceptions and comorbid conditions into the development of interventions that may improve both self-efficacy and medication adherence in T2DM.

Setting Measurement-Based Care in Motion: Practical Lessons in the Implementation and Integration of Measurement-Based Care in Psychiatry Clinical Practice

Measurement-based care (MBC) involves the systematic use of standardized measurements to inform treatment decisions. MBC can enhance clinical decision-making and quality of care by prompting personalized changes in treatment based on measured patient outcomes. MBC can also promote more precise communications between patients and clinicians around individual patient care. While commonly employed in psychiatric clinical research, the use of MBC in everyday practice can be complicated by clinic operations and variability across patients. We implemented MBC in the UT Southwestern Psychiatry Multispecialty Outpatient Clinic during the expansion of our general psychiatry clinic and subspecialty targeted programs. This article describes the top 10 lessons we learned as we confronted practical obstacles around implementing the ideals of MBC into a pre-existing, busy psychiatric clinical practice and how doing so impacts care, provider engagement, patient engagement, and research opportunity.

The Development and Psychometric Assessment of Chinese Medication Literacy Scale for Hypertensive Patients (C-MLSHP)

OBJECTIVE

To develop the medication literacy scale for patients with hypertension, and to test the reliability and validity of the scale.

METHODS

The initial draft of the scale was formulated based on the operationalization of medication literacy with four core elements of knowledge, attitude, skill, and practice, and was developed through procedures of literature review, interviews to hypertensive patients, and research group discussion. Expert panel meeting, interviews, and pre-test on the initial draft of the scale to 10 hypertensive patients, as well as a two iterations of expert feedback were used to form a primary medication literacy scale for pilot investigation and item selection. In this study, 260 patients with hypertension in Changsha city of China were purposively selected to conduct a pilot survey using the primary medication literacy scale. After item selection by a series of statistical analysis method and item re-wording according to patients' feedback, the scale was revised to form a formal investigation scale with four domains and 37 items. A formal investigation was carried out on 650 patients with hypertension selected purposively in a tertiary general hospital and two community health service centers in Changsha city of China. The reliability and validity of the scale were analyzed.

RESULTS

Finally, the formal scale consists of four domains on knowledge, attitude, practice and skills, 11 sub-factors and 37 items in total. The scale-level content validity index (S-CVI/Ave) of this scale was 0.968, and the I-CVI for each item ranged from 0.833 to 1.000, indicating a good and acceptable content and face validity. The Cronbach's α coefficient was 0.849 for the overall scale and ranged from 0.744 to 0.783 for domains. The Pearson's correlation coefficients between domains and the total scale were ranging from 0.530 to 0.799. Besides, the Pearson's correlation coefficient among domains of the scale ranged from 0.157 to 0.439. The Spearman-Brown split-half reliability coefficient was 0.893 for the total scale and ranged from 0.793 to 0.872 for domains. The test-retest reliability coefficient of the total scale was 0.968 and ranged from 0.880 to 0.959 for domains. Four domains of knowledge, attitude, skill, and practice were identified through the exploratory factor analysis and confirmatory factor analysis from each domain. The total explained variation of domains for the overall scale was 51.420%. Eleven sub-factors for domains were extracted through respective exploratory factor analysis from each domain, and the total explained variation of sub-factors for its belonging domain were ranging from 56.111 to 64.419%. The confirmatory factor analysis showed the fit indices of the four-domain model were as follows (χ2/df=2.629, GFI=0.804, AGFI=0.777, RMR=0.012, IFI=0.746, RMSEA=0.066, PNFI=0.599, PCFI=0.689), which indicated an acceptable model fit.

CONCLUSIONS

The medication literacy scale for hypertensive patients has good reliability and acceptable validity, which is suitable and acceptable for evaluating the medication literacy level of hypertension patients in China. In the future, further construct and model fit validation and English translation with appropriate adaptation of this whole scale are required, so that this scale can be further validated and applied worldwide.

Reliability, validity and measurement invariance of the Simplified Medication Adherence Questionnaire (SMAQ) among HIV-positive women in Ethiopia: a quasi-experimental study

BACKGROUND

Adherence to antiretroviral therapy is critical to the achievement of the third target of the UNAIDS Fast-Track Initiative goals of 2020-2030. Reliable, valid and accurate measurement of adherence are important for correct assessment of adherence and in predicting the efficacy of ART. The Simplified Medication Adherence Questionnaire is a six-item scale which assesses the perception of persons living with HIV about their adherence to ART. Despite recent widespread use, its measurement properties have yet to be carefully documented beyond the original study in Spain. The objective of this paper was to conduct internal consistency reliability, concurrent validity and measurement invariance tests for the SMAQ.

METHODS

HIV-positive women who were receiving ART services from 51 service providers in two sub-cities of Addis Ababa, Ethiopia completed the SMAQ in a HIV treatment referral network study between 2011 and 2012. Two cross-sections of 402 and 524 female patients of reproductive age, respectively, from the two sub-cities were randomly selected and interviewed at baseline and follow-up. We used Cronbach's coefficient alpha (α) to assess internal consistency reliability, Pearson product-moment correlation (r) to assess concurrent validity and multiple-group confirmatory factor analysis to analyze factorial structure and measurement invariance of the SMAQ.

RESULTS

All participants were female with a mean age of 33; median: 34 years; range 18-45 years. Cronbach's alphas for the six items of the SMAQ were 0.66, 0.68, 0.75 and 0.75 for T1 control, T1 intervention, T2 control, and T2 intervention groups, respectively. Pearson correlation coefficients were 0.78, 0.49, 0.52, 0.48, 0.76 and 0.80 for items 1 to 6, respectively, between T1 compared to T2. We found invariance for factor loadings, observed item intercepts and factor variances, also known as strong measurement invariance, when we compared latent adherence levels between and across patient-groups.

CONCLUSIONS

Our results show that the six-item SMAQ scale has adequate reliability and validity indices for this sample, in addition to being invariant across comparison groups. The findings of this study strengthen the evidence in support of the increasing use of SMAQ by interventionists and researchers to examine, pool and compare adherence scores across groups and time periods.

Translation and validation of the English version of the general medication adherence scale (GMAS) in patients with chronic illnesses

Objective: This study aimed to translate the General Medication Adherence Scale (GMAS) into English language and validate it in patients suffering from chronic illnesses. Methods: A 1-month study (January 2018) was conducted in a random sample of patients suffering from chronic illnesses who visited the outpatient departments of four tertiary healthcare facilities in Karachi, Pakistan. Translation of the tool and its content, as well as face validity, was carried out. Factor structure was explored (i.e. exploratory and partial confirmatory factor analyses were carried out) and fit indices were calculated for model fitting. Test-re-test reliability and internal consistency were analyzed. Validity of GMAS-English was established by convergent, discriminant, and concurrent validity analysis. Sensitivity analysis was conducted. Data was analyzed through SPSS version 23. The study was ethically approved by concerned authorities (Letter# NOV:15). Results: The GMAS was translated into English language by standard procedure. Factor analysis indicated a 3-factor model. Fit indices, namely normed fit index, Tucker Lewis index, comparative fit index, and root mean square of error approximation, were calculated with satisfactory results (i.e. NFI, TLI, and CFI > 0.9 and RMSEA < 0.08). Internal consistency (α) was 0.82. A high response rate of 91.6% was reported. GMAS-English established convergent, discriminant, and concurrent validities. The tool was sensitive (>75%) in screening patients with partial-to-low adherence based on their education level. Conclusion: The tool was translated in English language and demonstrated adequate internal consistency. The results indicate that GMAS-English is a valid and reliable tool to measure medication adherence in patients with chronic illness.

Development and Validation of a Novel General Medication Adherence Scale (GMAS) for Chronic Illness Patients in Pakistan

Objective: This study aimed to develop and validate a self-reporting adherence tool termed as General Medication Adherence Scale (GMAS) in Urdu language for measuring adherence toward medication use among Pakistani patients with a chronic disease. Methods: A month-long study (December 2017) was conducted in three tertiary health care settings of Karachi, Pakistan. The tool underwent content and face validity as well as factor analyses, i.e., exploratory, partial confirmatory and confirmatory factor analyses. Random sampling was conducted, and sample size was calculated using item response theory. The item-to-respondent ratio was 1:15. Fit indices namely normed fit index (NFI), Tucker Lewis index (TLI), comparative fit index (CFI), goodness of fit index (GFI), absolute goodness of fit (AGFI), parsimony goodness of fit index (PGFI), root mean square error of approximation (RMSEA), and standard root mean square residual (SRMR) were calculated. Additionally, estimation of the convergent, discriminant and known group validities, was conducted. Internal consistency was analyzed by test-retest reliability, McDonald's and Pearson correlation coefficient. The factor analyses were conducted using IBM SPSS version 22 and IBM SPSS AMOS version 25. Results: Content validity index (CVI) was reported at 0.8 (SD 0.147) and the tool was content validated with three hypothetical constructs. Factor analyses highlighted a 3-factor structure. The fit indices were calculated with satisfactory results, i.e., PGFI, GFI, AGFI, NFI, TLI, and CFI were greater than 0.9 and PGFI > 0.5. The values of RMSEA and SRMR were less than 0.07. A Cronbach's alpha value of 0.84 was obtained in reliability analysis. The test-retest Pearson's correlation coefficient value was reported at 0.996 (p-value < 0.01). Convergent and discriminant validities for all constructs and, known group validity for two constructs, were established. A high response rate of 91% was achieved in respondents. Patients without insurance coverage appeared to be low adherent compared to those with insurance coverage (p-value < 0.05). Non-comorbid patients were more likely to be highly adherent as compared to comorbid patients (p-value < 0.01). Conclusion: A novel tool GMAS was developed in Urdu language and was subsequently validated in patients with chronic diseases.

Factors Associated with Adherence to Transdermal Nicotine Patches within a Smoking Cessation Effectiveness Trial

BACKGROUND

Adherence to transdermal nicotine patches, one of the most popular and effective treatment for nicotine dependence, remains very low and is a strong predictor of cessation rates. This study examined individual factors related to adherence as well as differences over time between adherent (≥ 80% of daily patch use) and non-adherent participants (< 80% of daily patch use).

METHODS

We analyzed data from 440 participants who received 8 weeks of 21mg transdermal nicotine and 4 behavioral counseling sessions within an effectiveness trial that examined the effects of long-term treatment. Multiple logistical regression assessed baseline variables associated with patch adherence and generalized estimating equations (GEE) were used to evaluate changes in craving and withdrawal, depressive and anxiety symptoms, substitute and complementary reinforcers, and side effects between participants who were or were not adherent.

RESULTS

In a logistic regression model, being female, living with a child or children, and higher self-reported anxiety symptoms were predictive of lower patch adherence (p < .05). In the GEE analysis, adherence was significantly associated with: a greater reduction in craving, a greater engagement in substitute reinforcers, and a greater decrease in complementary reinforcers over time (p < .05).

CONCLUSIONS

Difficulties adhering to transdermal nicotine patches may be related to psychiatric comorbidity, difficulty managing nicotine craving, and challenges with engaging in substitute reinforcers and reducing exposure to complementary reinforcers. These constructs may serve as targets for interventions designed to increase treatment adherence.

The clinical utility of the Medication Adherence Questionnaire (MAQ) in an alcohol pharmacotherapy trial

BACKGROUND

Medication nonadherence is a ubiquitous problem in pharmacology treatment for alcohol use disorders. Unintentional and purposeful nonadherence as measured by the Medication Adherence Questionnaire (MAQ) has been shown to predict problems with medication adherence; however, feedback from the MAQ has never been incorporated into a behavioral intervention to facilitate medication adherence. We assessed the integration of the MAQ into medical management (MM), a counseling approach frequently employed in conjunction with alcohol pharmacotherapy, to determine whether prior patterns of nonadherence could be addressed effectively to promote medication adherence.

METHODS

We conducted a post-hoc analysis of data from 131 alcohol dependent smokers who participated in a double blind, placebo controlled study of varenicline for the treatment of alcohol dependence. At baseline, participants completed a single administration of the MAQ, which asks 2 questions about unintentional nonadherence (e.g., forgetting) and 2 questions about purposeful nonadherence (e.g., stopping because feeling good or feeling bad). Based on these responses, participants were divided into 1 of 3 three categories. Adherent (n=60), Unintentional or Purposeful Nonadherent (n=50) and Unintentional and Purposeful Nonadherent (n=21). Over the course of the 16-week treatment period, patients were expected to participate in 12 medical management (MM) sessions; a brief psychosocial treatment. Feedback based on the MAQ responses was integrated into the MM sessions to facilitate medication and treatment adherence.

RESULTS

The 3 adherence groups were compared on baseline characteristics, medication adherence, treatment attendance and end-of-treatment patient ratings of treatment helpfulness. Baseline demographics and characteristics were not significantly different among the three categories. We found no statistically significant differences among the three groups with respect to pill adherence, treatment attendance, and treatment satisfaction ratings.

CONCLUSIONS

The findings suggest that the incorporation of MAQ feedback into the MM approach could be effective in mitigating risks associated with prior patterns of nonadherence suggesting that further testing of the integrated behavioral approach is warranted.

Lessons learned in the development and evaluation of RxCoach™, an mHealth app to increase tobacco cessation medication adherence

OBJECTIVE

In this project we developed and evaluated a mobile health app to improve adherence to tobacco cessation medication.

METHODS

The study was conducted in three phases: (1) Create app with input from our consultant, focus groups and user testing; (2) Test feasibility of the app; and (3) Develop and user-test the barcode scanner.

RESULTS

Focus group feedback was instrumental in developing content and creating the user interface. User testing helped to identify problems and refine the app. The feasibility trial provided "real world" testing. We experienced challenges in recruitment due to the inclusion criteria. We had high attrition due to technical issues, medication side effects, enrollment procedures, and lack of personal contact. Among the five retained participants, use of the app was associated with good medication adherence and high consumer satisfaction.

CONCLUSION

The small sample size limits the generalizability of the findings and the conclusions that can be drawn from the study. However, the feasibility trial enabled the team to identify ways to improve the conduct of this and other mHealth studies.

PRACTICAL IMPLICATIONS

We should expand RxCoach to include all prescription and over-the-counter tobacco cessation medications, and re-test for feasibility using lessons learned to improve recruitment and retention.

A Preliminary Investigation of a Relapse Prevention Mobile Application to Maintain Smoking Abstinence Among Individuals With Posttraumatic Stress Disorder

OBJECTIVES

Smokers with posttraumatic stress disorder (PTSD) have increased difficulty achieving and maintaining abstinence. Contingency management approaches to smoking cessation interventions have demonstrated short-term efficacy but are limited by high rates of relapse. The goal of this pilot study was to evaluate the usability and feasibility of a smartphone-based smoking cessation application (Stay Quit Coach) designed to prevent relapse among individuals with PTSD.

METHODS

Smokers (N = 11) were randomized to (1) QUIT4EVER, an intervention combining mobile contingency management smoking cessation counseling and medications, and Stay Quit Coach or (2) a contact control condition that was identical to QUIT4EVER except Stay Quit Coach was not included. The primary outcome was prolonged smoking abstinence.

RESULTS

Among those queried during the follow-up periods, average Stay Quit Coach helpfulness ratings were high and ranged from 7.25 to 10 on a 10-point Likert scale (with higher scores corresponding to greater helpfulness). The Stay Quit Coach was rated by participants as being most effective at helping to quit smoking, helping to remain quit, and providing support and relevant information about quitting. Among the three quitters in the QUIT4EVER group, all reported abstinence at 3 and 6 months; however, abstinence was only bioverified for one quitter at 6 months. Among the four quitters in the contact control condition group, three reported abstinence at 3 and 6 months, but abstinence was not confirmed by bioverification.

CONCLUSIONS

Smokers with PTSD express interest in and helpfulness of Stay Quit Coach for remaining abstinent after a quit attempt. Combined use of mobile contingency management and Stay Quit Coach is a feasible and acceptable adjunctive smoking cessation treatment for reducing smoking among smokers with PTSD. Adequately powered clinical trials are needed to demonstrate the long-term efficacy of this combined approach to smoking cessation. This study [Use of Technological Advances to Prevent Smoking Relapse among Smokers with PTSD (QUIT4EVER)] was registered on www.clinicaltrials.gov . clinicaltrials.gov identifier: NCT01990079.

Psychometric Properties of the Four-Item Morisky Green Levine Medication Adherence Scale among Atherosclerosis Risk in Communities (ARIC) Study Participants

OBJECTIVES

To evaluate the reliability and factorial validity of the four-item Morisky Green Levine Medication Adherence Scale (MGLS) among Atherosclerosis Risk in Communities (ARIC) Study participants.

METHODS

We used the cross-sectional visit 5 data from the ARIC Study to assess the measurement properties of the MGLS. We measured the internal consistency using Cronbach α (where α > 0.70 is considered reliable for group-level measurement), the response frequency, and the inter item correlation. Factor analysis of the MGLS and five other adherence items in the survey was conducted using a polychoric correlation matrix to examine the dimensionality that underlies the MGLS. A vanishing tetrad test was conducted to assess conformity with an effect indicator model.

RESULTS

Among the ARIC visit 5 participants, 6,261 (96%) responded to the MGLS and other questions related to medication adherence in the survey (mean age 76 ± 5 years, 59% women). The Cronbach α for the MGLS was 0.47. The inter-item correlations ranged from 0.11 to 0.26. In the factor analysis of the medication adherence survey questions, a three-factor solution was used. One factor captured the extent of nonadherence, whereas other factors focused on the reasons for nonadherence. The MGLS items spread out across the factors that reflect the extent of as well as the reasons for nonadherence. The results of the vanishing tetrad test indicated that the MGLS consists of items other than effect indicators (P < 0.0001).

CONCLUSIONS

The low reliability together with the factor analysis findings imply that the MGLS may reflect causes as well as the extent of medication adherence. The findings suggest that the MGLS, as presently used, lacks consistency in an elderly population.

A Randomised Controlled Trial to Test the Effectiveness of Planning Strategies to Improve Medication Adherence in Patients with Cardiovascular Disease

BACKGROUND

Low levels of adherence to medication prescribed to treat and manage chronic disease may lead to maladaptive health outcomes. Theory-based, easy-to-administer interventions that promote patients' effective self-regulation of their medication-taking behaviour are needed if adherence is to be maximised. We tested the effectiveness of an intervention adopting planning techniques to promote medication adherence.

METHODS

Outpatients with cardiovascular disease (N = 71) were allocated to either an experimental condition, in which participants were asked to form implementation intentions and coping plans related to their treatment, or to a no-planning control condition, in which participants received no treatment. Patients also completed self-report measures of medication adherence, self-efficacy, and beliefs in medication necessity and concerns. Measures were administered at baseline and at 6-week follow-up.

RESULTS

Results revealed no overall main effect for the intervention on medication adherence. Post-hoc moderator analyses revealed that the intervention was effective in patients with lower necessity beliefs compared to those with higher necessity beliefs.

CONCLUSION

While current findings have promise in demonstrating the conditional effects of planning interventions, there is a need to replicate these findings by manipulating planning and beliefs independently and testing their direct and interactive effects on medication adherence.

Looking beyond patients: Can parents' quality of life predict asthma control in children?

BACKGROUND

Social and family factors may influence the probability of achieving asthma control in children. Parents' quality of life has been insufficiently explored as a predictive factor linked to the probability of achieving disease control in asthmatic children.

OBJECTIVE

Determine whether the parents' quality of life predicts medium-term asthma control in children.

METHODS

Longitudinal study of children between 4 and 14 years of age, with active asthma. The parents' quality of life was evaluated using the specific IFABI-R instrument, in which scores were higher for poorer quality of life. Its association with asthma control measures in the child 16 weeks later was analyzed using multivariate methods, adjusting the effect for disease, child and family factors.

RESULTS

The data from 452 children were analyzed (median age 9.6 years, 63.3% males). The parents' quality of life was predictive for asthma control; each point increase on the initial IFABI-R score was associated with an adjusted odds ratio (95% confidence interval) of 0.56 (0.37-0.86) for good control of asthma on the second visit, 2.58 (1.62-4.12) for asthma exacerbation, 2.12 (1.33-3.38) for an unscheduled visit to the doctor, and 2.46 (1.18-5.13) for going to the emergency room. The highest quartile for the IFABI-R score had a sensitivity of 34.5% and a specificity of 82.2% to predict poorly controlled asthma.

CONCLUSIONS

Parents' poorer quality of life is related to poor, medium-term asthma control in children. Assessing the parents' quality of life could aid disease management decisions. Pediatr Pulmonol. 2016;51:670-677. © 2015 Wiley Periodicals, Inc.

Validity and Reliability of a Self-Reported Measure of Antihypertensive Medication Adherence in Uganda

Background

The Morisky Medication Adherence scale (MMAS-8) is a widely used self-reported measure of adherence to antihypertensive medications that has not been validated in hypertensive patients in sub-Saharan Africa.

Methods

We carried out a cross-sectional study to examine psychometric properties of a translated MMAS-8 (MMAS-U) in a tertiary care hypertension clinic in Uganda. We administered the MMAS-U to consecutively selected hypertensive adults and used principal factor analysis and Cronbach’s alpha to determine its validity and internal consistency respectively. Then we randomly selected one-sixth of participants for a 2-week test-retest telephone interview. Lastly, we used ordinal logistic regression modeling to explore factors associated with levels of medication adherence.

Results

Of the 329 participants, 228 (69%) were females, median age of 55 years [Interquartile range (IQR) (46–66)], and median duration of hypertension of 4 years [IQR (2–8)]. The adherence levels were low (MMAS-U score ≤ 5) in 85%, moderate (MMAS-U score 6–7) in 12% and high (MMAS-U score ≥8) in 3%. The factor analysis of construct validity was good (overall Kaiser’s measure of sampling adequacy for residuals of 0.72) and identified unidimensionality of MMAS-U. The internal consistency of MMAS-U was moderate (Cronbach α = 0.65), and test-retest reliability was low (weighted kappa = 0.36; 95% CI -0.01, 0.73). Age of 40 years or greater was associated with low medication adherence (p = 0.02) whereas a family member buying medication for participants (p = 0.02) and purchasing medication from a private clinic (p = 0.02) were associated with high adherence.

Conclusion

The Ugandan version of the MMAS-8 (MMAS-U) is a valid and reliable measure of adherence to antihypertensive medication among Ugandan outpatients receiving care at a public tertiary facility. Though the limited supply of medication affected adherence, this easy to use tool can be adapted to assess medication adherence among adults with hypertension in Uganda.

Zonisamide Reduces Withdrawal Symptoms But Does Not Enhance Varenicline-Induced Smoking Cessation

INTRODUCTION

Varenicline (Chantix) is a first-line treatment for smoking cessation but does not produce cessation in many individuals. It may be possible to improve abstinence by co-administering varenicline with other medications. Zonisamide (Zonegran) has a similar pharmacologic profile to topiramate, which has been shown to reduce smoking, but is better tolerated. This study evaluated whether combined zonisamide and varenicline reduced tobacco withdrawal and increased abstinence among smokers trying to quit, relative to varenicline and placebo.

METHODS

This was a double-blind, randomized, placebo-controlled pilot trial of zonisamide + varenicline versus placebo + varenicline for smoking cessation. Smokers received brief counseling and study medications, and completed weekly assessments for 10 consecutive weeks. The primary outcome was continuous abstinence rates (biochemically verified) during the final 4 weeks of treatment.

RESULTS

Results are presented as intent-to-treat and completer analyses. Seventy-four individuals were enrolled; 45 completed the study. Overall, 14.9% (intent-to-treat) and 25.0% (completer) of participants maintained sustained abstinence during the final 4 weeks of treatment. There were no differences between groups for biochemically-verified smoking, but zonisamide + varenicline reduced self-reported smoking, nicotine withdrawal, and craving compared to placebo + varenicline.

CONCLUSIONS

Zonisamide decreased nicotine withdrawal and craving, though not of sufficient magnitude to modify smoking behavior. The sample size was small and low rates of abstinence across groups suggest the study population was difficult to treat. Additional evaluation of zonisamide or other medications that increase GABA or decrease glutamate in larger or more diverse populations may yield positive clinical benefit for nicotine/tobacco cessation.

IMPLICATIONS

This study provides support for layering novel medications with varenicline for smoking cessation, for investigating medications that target the GABA and glutamate system, and for assessing the contribution that reductions in nicotine withdrawal have on ultimate cessation outcomes.

Medication Adherence Measures: An Overview

WHO reported that adherence among patients with chronic diseases averages only 50% in developed countries. This is recognized as a significant public health issue, since medication nonadherence leads to poor health outcomes and increased healthcare costs. Improving medication adherence is, therefore, crucial and revealed on many studies, suggesting interventions can improve medication adherence. One significant aspect of the strategies to improve medication adherence is to understand its magnitude. However, there is a lack of general guidance for researchers and healthcare professionals to choose the appropriate tools that can explore the extent of medication adherence and the reasons behind this problem in order to orchestrate subsequent interventions. This paper reviews both subjective and objective medication adherence measures, including direct measures, those involving secondary database analysis, electronic medication packaging (EMP) devices, pill count, and clinician assessments and self-report. Subjective measures generally provide explanations for patient's nonadherence whereas objective measures contribute to a more precise record of patient's medication-taking behavior. While choosing a suitable approach, researchers and healthcare professionals should balance the reliability and practicality, especially cost effectiveness, for their purpose. Meanwhile, because a perfect measure does not exist, a multimeasure approach seems to be the best solution currently.

Psychometric evaluation of a Korean version of the 8-item Medication Adherence Scale in rural older adults with hypertension

OBJECTIVE

To examine the psychometric properties of a structured self-reported 8-item Korean-version Morisky Medication Adherence Scale (MMAS-K) among rural older adults with hypertension.

DESIGN

Cross-sectional descriptive survey.

SETTING

A rural community comprising three primary health care posts in Gangwon Province, South Korea.

PARTICIPANTS

Ninety-two older adults with hypertension who received treatment at primary health care posts.

MAIN OUTCOME MEASURES

Participants completed an 8-item MMAS-K questionnaire, and the community health practitioners manually measured blood pressure. Factor analysis and correlation coefficient for validity and the Kuder-Richardson alpha coefficient for reliability of the MMAS-K were used, while the association between medication adherence and blood pressure control was determined using Fisher's exact test.

RESULTS

Internal consistency reliability was acceptable with a coefficient alpha of 0.71. The factor analysis of construct validity identified two dimensions of the 8-item MMAS-K, explaining 52.22% of the total variance. There was a high correlation between the 8-item MMAS-K and the original 4-item MMAS (r = 0.874), indicating that these scales measure theoretically related constructs for convergent validity. There was a significant association between the 8-item MMAS-K score and blood pressure control (P < 0.05), indicating that, for the known-groups validity, the controlled blood pressure group was more likely to have higher rate of medication adherence than the poor-control group.

CONCLUSIONS

The findings indicate a positive association between medication adherence and blood pressure control. The 8-item MMAS-K possesses adequate validity and reliability among rural older adults with hypertension.

Rationale and design of a randomized controlled trial of varenicline directly observed therapy delivered in methadone clinics

Background

Tobacco cessation medication adherence is one of the few factors shown to improve smoking cessation rates among methadone-maintained smokers, but interventions to improve adherence to smoking cessation medications have not yet been tested among methadone treatment patients. Methadone clinic-based, directly observed therapy (DOT) programs for HIV and tuberculosis improve adherence and clinical outcomes, but have not been evaluated for smoking cessation. We describe a randomized controlled trial to evaluate whether a methadone clinic-based, directly observed varenicline therapy program increases adherence and tobacco abstinence among opioid-dependent drug users receiving methadone treatment.

Methods/Design

We plan to enroll 100 methadone-maintained smokers and randomize them to directly observed varenicline dispensed with daily methadone doses or treatment as usual (self-administered varenicline) for 12 weeks. Our outcome measures are: 1) pill count adherence and 2) carbon monoxide-verified tobacco abstinence. We will assess differences in adherence and abstinence between the two treatment arms using repeated measures models.

Discussion

This trial will allow for rigorous evaluation of the efficacy of methadone clinic-based, directly observed varenicline for improving adherence and smoking cessation outcomes. This detailed description of trial methodology can serve as a template for the development of future DOT programs and can guide protocols for studies among opioid-dependent smokers receiving methadone treatment.

Trial Registration

clinicaltrials.gov NCT01378858

Beliefs, experience, and interest in pharmacotherapy among smokers with HIV

OBJECTIVES

To examine beliefs, prior use, and interest in using pharmacotherapy among people living with HIV/AIDS (PLWHA).

METHODS

Cross-sectional survey of smokers in a midwestern HIV clinic.

RESULTS

The sample (N = 146) included 69% men, 82% African Americans, 45% were in precontemplation for quitting, and 46% were interested in using pharmacotherapy. Primary reasons for non-use included cost and a belief that they would be able to quit on their own. Physician assistance was the strongest correlate of prior use. Perceived benefits and self-efficacy were the strongest correlates of willingness to use pharmacotherapy.

CONCLUSIONS

Future interventions should address misconceptions, perceived benefits, and self-efficacy for using cessation aids. Physicians should offer pharmacotherapy to all smokers.

What are validated self-report adherence scales really measuring?: a systematic review

AIMS

Medication non-adherence is a significant health problem. There are numerous methods for measuring adherence, but no single method performs well on all criteria. The purpose of this systematic review is to (i) identify self-report medication adherence scales that have been correlated with comparison measures of medication-taking behaviour, (ii) assess how these scales measure adherence and (iii) explore how these adherence scales have been validated.

METHODS

Cinahl and PubMed databases were used to search articles written in English on the development or validation of medication adherence scales dating to August 2012. The search terms used were medication adherence, medication non-adherence, medication compliance and names of each scale. Data such as barriers identified and validation comparison measures were extracted and compared.

RESULTS

Sixty articles were included in the review, which consisted of 43 adherence scales. Adherence scales include items that either elicit information regarding the patient's medication-taking behaviour and/or attempts to identify barriers to good medication-taking behaviour or beliefs associated with adherence. The validation strategies employed depended on whether the focus of the scale was to measure medication-taking behaviour or identify barriers or beliefs.

CONCLUSIONS

Supporting patients to be adherent requires information on their medication-taking behaviour, barriers to adherence and beliefs about medicines. Adherence scales have the potential to explore these aspects of adherence, but currently there has been a greater focus on measuring medication-taking behaviour. Selecting the 'right' adherence scale(s) requires consideration of what needs to be measured and how (and in whom) the scale has been validated.

What are validated self-report adherence scales really measuring?: a systematic review

AIMS

Medication non-adherence is a significant health problem. There are numerous methods for measuring adherence, but no single method performs well on all criteria. The purpose of this systematic review is to (i) identify self-report medication adherence scales that have been correlated with comparison measures of medication-taking behaviour, (ii) assess how these scales measure adherence and (iii) explore how these adherence scales have been validated.

METHODS

Cinahl and PubMed databases were used to search articles written in English on the development or validation of medication adherence scales dating to August 2012. The search terms used were medication adherence, medication non-adherence, medication compliance and names of each scale. Data such as barriers identified and validation comparison measures were extracted and compared.

RESULTS

Sixty articles were included in the review, which consisted of 43 adherence scales. Adherence scales include items that either elicit information regarding the patient's medication-taking behaviour and/or attempts to identify barriers to good medication-taking behaviour or beliefs associated with adherence. The validation strategies employed depended on whether the focus of the scale was to measure medication-taking behaviour or identify barriers or beliefs.

CONCLUSIONS

Supporting patients to be adherent requires information on their medication-taking behaviour, barriers to adherence and beliefs about medicines. Adherence scales have the potential to explore these aspects of adherence, but currently there has been a greater focus on measuring medication-taking behaviour. Selecting the 'right' adherence scale(s) requires consideration of what needs to be measured and how (and in whom) the scale has been validated.

Opioid antagonists for smoking cessation

BACKGROUND

The reinforcing properties of nicotine may be mediated through release of various neurotransmitters both centrally and systemically. People who smoke report positive effects such as pleasure, arousal, and relaxation as well as relief of negative affect, tension, and anxiety. Opioid (narcotic) antagonists are of particular interest to investigators as potential agents to attenuate the rewarding effects of cigarette smoking.

OBJECTIVES

To evaluate the efficacy of opioid antagonists in promoting long-term smoking cessation. The drugs include naloxone and the longer-acting opioid antagonist naltrexone.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register for trials of naloxone, naltrexone and other opioid antagonists and conducted an additional search of MEDLINE using 'Narcotic antagonists' and smoking terms in April 2013. We also contacted investigators, when possible, for information on unpublished studies.

SELECTION CRITERIA

We considered randomised controlled trials comparing opioid antagonists to placebo or an alternative therapeutic control for smoking cessation. We included in the meta-analysis only those trials which reported data on abstinence for a minimum of six months. We also reviewed, for descriptive purposes, results from short-term laboratory-based studies of opioid antagonists designed to evaluate psycho-biological mediating variables associated with nicotine dependence.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the study population, the nature of the drug therapy, the outcome measures, method of randomisation, and completeness of follow-up. The main outcome measure was abstinence from smoking after at least six months follow-up in patients smoking at baseline. Abstinence at end of treatment was a secondary outcome. We extracted cotinine- or carbon monoxide-verified abstinence where available. Where appropriate, we performed meta-analysis, pooling risk ratios using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

Eight trials of naltrexone met inclusion criteria for meta-analysis of long-term cessation. One trial used a factorial design so five trials compared naltrexone versus placebo and four trials compared naltrexone plus nicotine replacement therapy (NRT) versus placebo plus NRT. Results from 250 participants in one long-term trial remain unpublished. No significant difference was detected between naltrexone and placebo (risk ratio (RR) 1.00; 95% confidence interval (CI) 0.66 to 1.51, 445 participants), or between naltrexone and placebo as an adjunct to NRT (RR 0.95; 95% CI 0.70 to 1.30, 768 participants). The estimate was similar when all eight trials were pooled (RR 0.97; 95% CI 0.76 to 1.24, 1213 participants). In a secondary analysis of abstinence at end of treatment, there was also no evidence of any early treatment effect, (RR 1.03; 95% CI 0.88 to 1.22, 1213 participants). No trials of naloxone or buprenorphine reported abstinence outcomes.

AUTHORS' CONCLUSIONS

Based on data from eight trials and over 1200 individuals, there was no evidence of an effect of naltrexone alone or as an adjunct to NRT on long-term smoking abstinence, with a point estimate strongly suggesting no effect and confidence intervals that make a clinically important effect of treatment unlikely. Although further trials might narrow the confidence intervals they are unlikely to be a good use of resources.

Temporal patterns of adherence to medications and behavioral treatment and their relationship to patient characteristics and treatment response

BACKGROUND

The primary analyses of the COMBINE Study revealed significant naltrexone and Combined Behavioral Intervention (CBI) main effects on drinking outcomes but failed to find additional benefits of the combination of treatments. Investigating differences in patterns of adherence over time may shed light on the treatment effects in COMBINE. The goals of the study were to identify trajectories of medication adherence and participation in CBI, to estimate predictive and moderating effects of adherence trajectories on drinking outcomes and to characterize subjects in adherence trajectories. The results of these analyses may suggest approaches to improving adherence in order to ultimately improve treatment outcome.

METHODS

We used a trajectory-based approach to identify patterns of treatment adherence separately for naltrexone, acamprosate and CBI adherence. Logistic regression and general linear models assessed associations among adherence trajectories, drinking outcomes and patient characteristics.

RESULTS

Three trajectories of adherence were identified for each treatment: "excellent adherers", "late non-adherers" and "early non-adherers" and there was good agreement among adherence trajectories with different treatments. "Excellent adherers" had significantly higher percent days abstinent (PDA) and lower percent heavy drinking days (PHDD). CBI significantly decreased PHDD for subjects on acamprosate in the "early non-adherers with medication" trajectory (p=0.01). Either naltrexone or acamprosate was associated with lower PHDD than placebo for "early non-adherers with CBI" (p<0.01). Receiving active medication decreased the likelihood to be in the excellent medication adherence trajectory. Younger age, greater drinking severity, dissatisfaction with the medicine and session frequency, adverse events and lack of benefit were related to less favorable medication adherence trajectories. "Excellent adherers with CBI" were significantly more satisfied with the CBI counselor.

CONCLUSIONS

Patterns of treatment adherence appear to be a participant characteristic. Individuals who fail to adhere early in treatment have worse outcomes regardless of treatment. However, treatment outcomes of participants who exhibit early problems with adherence to one treatment modality could potentially be improved by offering an alternative behavioral or pharmacologic treatment.

Co-occurring marijuana use is associated with medication nonadherence and nonplanning impulsivity in young adult heavy drinkers

Few studies have examined the co-occurrence of alcohol and marijuana use in clinical samples of young adults. The present study investigated whether co-occurring marijuana use is associated with characteristics indicative of a high level of risk in young adult heavy drinkers. Individuals between the ages of 18 and 25 years (N=122) participated in an ongoing 8-week randomized clinical trial that tested the efficacy of placebo-controlled naltrexone plus brief individual counseling to reduce heavy drinking. At intake participants completed self-report assessments on alcohol consumption, alcohol-related negative consequences, motivation to reduce drinking, trait impulsivity, expectancies for alcohol-induced disinhibition, use of cigarettes, and history of medication nonadherence. In univariate tests heavy drinkers with and without co-occurring marijuana use did not differ on alcohol consumption, most alcohol-related negative consequences, and motivation to reduce drinking. In multivariate tests controlling for demographic characteristics, co-occurring heavy alcohol and marijuana use was significantly associated with nonplanning impulsivity (β=2.95) and a history of both unintentional (adjusted odds ratio [aOR]=3.30) and purposeful (aOR=3.98) nonadherence to medication. Findings suggest that young adult heavy drinkers with co-occurring marijuana use exhibit a high-risk clinical profile and may benefit from interventions that increase adherence to medications.

Adherence to varenicline among African American smokers: an exploratory analysis comparing plasma concentration, pill count, and self-report

INTRODUCTION

Measuring adherence to smoking cessation pharmacotherapy is important to evaluating its effectiveness. Blood levels are considered the most accurate measure of adherence but are invasive and costly. Pill counts and self-report are more practical, but little is known about their relationship to blood levels. This study compared the validity of pill count and self-report against plasma varenicline concentration for measuring pharmacotherapy adherence.

METHODS

Data were obtained from a randomized pilot study of varenicline for smoking cessation among African American smokers. Adherence was measured on Day 12 via plasma varenicline concentration, pill count, 3-day recall, and a visual analogue scale (VAS; adherence was represented on a line with two extremes "no pills" and "all pills").

RESULTS

The sample consisted of 55 African American moderate to heavy smokers (average 16.8 cigarettes/day, SD = 5.6) and 63.6% were female. Significant correlations (p < .05) were found between plasma varenicline concentration and pill count (r = .56), 3-day recall (r = .46), and VAS (r = .29). Using plasma varenicline concentration of 2.0 ng/ml as the cutpoint for adherence, pill count demonstrated the largest area under the receiver operating characteristic curve (AUC = 0.85, p = .01) and had 88% sensitivity (95% CI = 75.0-95.0) and 80% specificity (95% CI = 30.0-99.0) for detecting adherence.

CONCLUSIONS

Of 3 commonly used adherence measures, pill count was the most valid for identifying adherence in this sample of African American smokers. Pill count has been used across other health domains and could be incorporated into treatment to identify nonadherence, which, in turn, could maximize smoking cessation pharmacotherapy use and improve abstinence rates.

Choosing not to take phosphate binders: the role of dialysis patients' medication beliefs

OBJECTIVE

Patients with end-stage renal disease (ESRD) receiving haemodialysis are at risk of cardiovascular disease and bone disorders related to high levels of serum phosphate (PO(4)). Phosphate binders are an important treatment; however, non-adherence remains a significant issue. This study investigates whether patients' beliefs about medicines predict intentional non-adherence to phosphate binders.

METHOD

This was a cross-sectional study of ESRD patients (n = 76). Non-adherence was measured in two ways: (1) the self-report Medication Adherence Questionnaire (MAQ) and (2) 3-month average level of serum phosphate. The Beliefs about Medicines questionnaire was used to assess general and specific beliefs towards phosphate medicines.

RESULTS

Eleven (14.5% of 76) patients reported being intentionally non-adherent to phosphate binders. Patients' beliefs that phosphate binders were less necessary were significantly associated with intentional self-reported non- adherence. Furthermore, patients with greater concerns about phosphate binders had higher serum phosphate levels.

CONCLUSION

Assessing patient beliefs about medicines is a reliable indicator of intentional non-adherence to treatment with phosphate binders. These findings may help in identifying ways in which adherence rates to phosphate binders can be improved.

Varenicline for smoking cessation: nausea severity and variation in nicotinic receptor genes

This study evaluated association between common and rare sequence variants in 10 nicotinic acetylcholine receptor subunit genes and the severity of nausea 21 days after initiating the standard, FDA-approved varenicline regimen for smoking cessation. Included in the analysis were 397 participants from a randomized clinical effectiveness trial with complete clinical and DNA resequencing data (mean age = 49.2 years; 68.0% female). Evidence for significant association between common sequence variants in CHRNB2 and nausea severity was obtained after adjusting for age, gender, and correlated tests (all P_ACT<.05). Individuals with the minor allele of CHRNB2 variants experienced less nausea than did those without the minor allele, consistent with previously reported findings for CHRNB2 and the occurrence of nausea and dizziness as a consequence of first smoking attempt in adolescents, and with the known neurophysiology of nausea. As nausea is the most common reason for discontinuance of varenicline, further pharmacogenetic investigations are warranted.

Adherence to varenicline in the COMPASS smoking cessation intervention trial

INTRODUCTION

Patient adherence to smoking cessation medications can impact their effectiveness. It is important to understand the extent to which prescribed medications are actually taken by smokers, how this influences smoking cessation outcomes, and what factors may influence adherence.

METHODS

Smokers recruited from a large health plan were randomized to receive different modes of cessation counseling in combination with varenicline (Swan, G. E., McClure, J. B., Jack, L. M., Zbikowski, S. M., Javitz, H. S., Catz, S. L., et al. 2010.Behavioral counseling and varenicline treatment for smoking cessation. American Journal of Preventive Medicine, 38, 482-490). One thousand one hundred and sixty-one participants were mailed a 28-day varenicline supply when they set a quit date and were able to request up to two refills from the health plan pharmacy at no cost. Pharmacy fill records were obtained and telephone surveys completed at baseline, 21 days, 12 weeks, and 6 months post target quit date.

RESULTS

Good adherence to varenicline (≥80% of days taken) was associated with a twofold increase in 6-month quit rates compared with poor adherence (52% vs. 25%). Smokers were more likely than nonsmokers to stop varenicline early. Purposeful nonadherence was associated with smoking at 12 weeks and was predicted in multivariate analyses by age, gender, adherence self-efficacy, and initial medication side effect severity.

CONCLUSIONS

Innovative methods for increasing adherence to smoking cessation medications are needed, particularly early in the quit process. Simple metrics of adherence such as number of days cessation medication is taken can and should be routinely incorporated in effectiveness trials and reported to advance future attempts to understand and reduce nonadherence.

Medications for unhealthy alcohol use: across the spectrum

The prevalence of unidentified or untreated unhealthy alcohol use remains high. With the advent of pharmacotherapy and models of counseling appropriate for use in primary care settings as well as in specialty care, clinicians have new tools to manage the range of alcohol problems across the spectrum of health care settings. By extending treatment to primary care, many people who do not currently receive specialty care may have increased access to treatment. In addition, primary care providers, by virtue of their ongoing relationship with patients, may be able to provide continuing treatment over time. Extending the spectrum of care to hazardous drinkers who may not be alcohol dependent could result in earlier intervention and reduce the consequences of excessive drinking.

Unannounced telephone pill counts for assessing varenicline adherence in a pilot clinical trial

BACKGROUND

Despite consistent evidence linking smoking cessation pharmacotherapy adherence to better outcomes, knowledge about objective adherence measures is lacking and little attention is given to monitoring pharmacotherapy use in smoking cessation clinical trials.

OBJECTIVES

To examine unannounced telephone pill counts as a method for assessing adherence to smoking cessation pharmacotherapy.

RESEARCH DESIGN

Secondary data analysis of a randomized pilot study.

PARTICIPANTS

46 moderate-to-heavy (>10 cigarettes per day) African-American smokers.

MAIN MEASURES

Smokers received 1 month of varenicline (Pfizer Global Pharmaceuticals, New York, NY) in a pill box at baseline. Unannounced pill counts were completed by telephone 4 days prior to an in-person pill count conducted at Month 1. At both counts, each compartment of the pill box was opened and the number of remaining pills was recorded.

RESULTS

Participants were a mean age of 48 years (SD = 13), predominately female (59%), low income (60% < $1800 monthly family income), and smoked an average of 17 (SD = 7) cigarettes per day. A high degree of concordance was observed between the number of pills counted by phone and in-person (r(s) = 0.94, P < 0.001). Participants with discordant counts (n = 7) had lower varenicline adherence (mean [SD] = 77% [18%] vs 95% [9%], P < 0.0005), but reported better medication adherence in the past (1.0 [0.8] vs 2.8 [1.0], P < 0.0004) than participants with matching phone and in-person counts (n = 39).

CONCLUSION

Unannounced telephone pill counts appear to be a reliable and practical method for measuring adherence to smoking cessation pharmacotherapy.

Endogenous opiates and behavior: 2007

This paper is the thirtieth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2007 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.

Impact of symptoms experienced by varenicline users on tobacco treatment in a real world setting

This article examines reported symptoms, nonsmoking rates, and medication use among 1,018 smokers using varenicline in a randomized trial comparing three forms of behavioral support for smoking cessation (phone, Web, or phone + Web). One month after beginning varenicline, 168 people (17%) had discontinued the medication. Most (53%) quit due to side effects and other symptoms. The most common side effect among all users was nausea (reported by 57% of users). At 1 month post medication initiation, those not taking varenicline were more likely to report smoking than those who continued the medication (57% vs. 16%, p < .001). Women reported more symptoms but did not discontinue medication at higher rates. Participants who received any telephone counseling (n = 681) were less likely to discontinue their medication than those with Web support only (15% vs. 21%, p < .01). Counseling may improve tolerance of this medication and reduce the rate of discontinuation due to side effects.

Opioid antagonists for smoking cessation

BACKGROUND

The reinforcing properties of nicotine may be mediated through release of various neurotransmitters both centrally and systemically. Smokers report positive effects such as pleasure, arousal, and relaxation as well as relief of negative affect, tension, and anxiety. Opioid (narcotic) antagonists are of particular interest to investigators as potential agents to attenuate the rewarding effects of cigarette smoking.

OBJECTIVES

To evaluate the efficacy of opioid antagonists in promoting long-term smoking cessation. The drugs include naloxone and the longer-acting opioid antagonist naltrexone.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group specialized register for trials of naloxone, naltrexone and other opioid antagonists and conducted an additional search of MEDLINE using 'Narcotic antagonists' and smoking terms in March 2006. We also contacted investigators, when possible, for information on unpublished studies.

SELECTION CRITERIA

We considered randomized controlled trials comparing opioid antagonists to placebo or an alternative therapeutic control for smoking cessation. We included in the meta-analysis only those trials which reported data on abstinence for a minimum of six months. We also reviewed, for descriptive purposes, results from short-term laboratory-based studies of opioid antagonists designed to evaluate psycho-biological mediating variables associated with nicotine dependence.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the type of study population, the nature of the drug therapy, the outcome measures, method of randomization, and completeness of follow up. The main outcome measure was cotinine- or carbon monoxide-verified abstinence from smoking after at least six months follow up in patients smoking at baseline. Where appropriate, we performed meta-analysis using a fixed-effect model (Mantel-Haenszel odds ratios).

MAIN RESULTS

Four trials of naltrexone met inclusion criteria for meta-analyses for long-term cessation. All four trials failed to detect a significant difference in quit rates between naltrexone and placebo. In a pooled analysis there was no significant effect of naltrexone on long-term abstinence, and confidence intervals were wide (odds ratio 1.26, 95% confidence interval 0.80 to 2.01). No trials of naloxone or buprenorphine reported long-term follow up.

AUTHORS' CONCLUSIONS

Based on limited data from four trials it is not possible to confirm or refute whether naltrexone helps smokers quit. The confidence intervals are compatible with both clinically significant benefit and possible negative effects of naltrexone in promoting abstinence. Data from larger trials of naltrexone are needed to settle the question of efficacy for smoking cessation.